A novel technique for a difficult breech delivery.

BACKGROUND: Breech presentation and delivery are important complications of labor and delivery, which, although dealt with by the emergency physician infrequently, can represent major morbidity and mortality to both the mother and fetus if techniques are not performed correctly. OBJECTIVES: We aim to describe a technique for breech delivery that was used successfully when all conventional techniques had failed. To our knowledge, this technique has not been described in previous literature. CASE REPORT: A 36-year-old woman presented to an urban emergency department in active labor. The physicians were called to the triage area, and found the patient lying on the floor with a limp, cyanotic-appearing fetus delivered to the level of the mid thorax. The arms and shoulders were delivered successfully, but after all traditional maneuvers to deliver the head were unsuccessful, a novel approach was used successfully and is described in this report. CONCLUSION: We have described a novel, seemingly safe, and effective technique to use in breech delivery when traditional techniques have failed.

Entrustment Decision Making: Extending Miller's Pyramid.

The iconic Miller's pyramid, proposed in 1989, characterizes 4 levels of assessment in medical education ("knows," "knows how," "shows how," "does"). The frame work has created a worldwide awareness of the need to have different assessment approaches for different expected outcomes of education and training. At the time, Miller stressed the innovative use of simulation techniques, geared at the third level ("shows how"); however, the "does" level, assessment in the workplace, remained a largely uncharted area. In the 30 years since Miller's conference address and seminal paper, much attention has been devoted to procedures and instrument development for workplace-based assessment. With the rise of competency-based medical education (CBME), the need for approaches to determine the competence of learners in the clinical workplace has intensified. The proposal to use entrustable professional activities as a framework of assessment and the related entrustment decision making for clinical responsibilities at designated levels of supervision of learners (e.g., direct, indirect, and no supervision) has become a recent critical innovation of CBME at the "does" level. Analysis of the entrustment concept reveals that trust in a learner to work without assistance or supervision encompasses more than the observation of "doing" in practice (the "does" level). It implies the readiness of educators to accept the inherent risks involved in health care tasks and the judgment that the learner has enough experience to act appropriately when facing unexpected challenges. Earning this qualification requires qualities beyond observed proficiency, which led the authors to propose adding the level "trusted" to the apex of Miller's pyramid.

Implementation of a Novel Conference Series on Clinical Practice Variations Provides an Opportunity for Constructive Discussion of Faculty Practice Patterns: Do as We Say? or Do as We Do?

BACKGROUND: Although evidence-based medicine (EBM) is routinely used to guide management in the emergency department, there is still considerable variation in clinical practice. Trainees may not fully appreciate the reasons for these clinical practice variations (CPVs) and may find it frustrating when they encounter them. We used areas of CPV among our faculty as the basis for resident educational sessions and assessed the perceived utility of these sessions. METHODS: Topics were identified when residents noticed significant variability among the faculty in their management of particular clinical presentations. Sessions were conducted by facilitator-led reviews of EBM guidelines, by faculty panel discussions of their management rationale where EBM guidelines are not available, or by pro-con debates. Residents were surveyed after the initial sessions to assess the utility of this series and changes in their understanding of CPV. RESULTS: There was a 72% response rate. The percentage of residents who were frustrated with CPV decreased from 64% to 35%; the percentage who felt that the presence of CPV enhanced their learning increased from 19% to 48%. Sixty-five percent felt that the educational series contributed to decreased frustration, 77% felt that the sessions helped them understand why CPV occurs, and 93% felt that they helped their overall learning. CONCLUSION: Explicit discussion and exploration of CPV in an educational setting can provide multiple benefits. Trainees may gain a better understanding of why CPV occurs and of the rationale behind practice variations. Faculty may benefit from analyzing CPV to determine whether these truly represent the "art of medicine."